An Evidence-Based Algorithm for Determining Venous Thromboembolism Prophylaxis After Degenerative Spinal Surgery

Safety and efficacy of apixaban vs. enoxaparin in thromboprophylaxis after spinal stenosis and degenerative spine surgery

INTRODUCTION

Degenerative spine surgeries often require postoperative immobilization or reduced mobility, predisposing patients to the formation of thrombosis and higher risk of thromboembolic complications. Despite the significance of this issue, there remains a lack of consensus on the optimal anticoagulant agent for postoperative thromboprophylaxis in spinal stenosis and degenerative spine surgeries. Low molecular weight heparins and direct Xa inhibitors represent two anticoagulant groups with high chemoprophylactic potential.

METHODS

This study included a prospective cohort of patients undergoing posterior decompressive surgery with or without instrumentation for degenerative spine disease and/or spinal stenosis. Patients receiving postoperative prophylactic Enoxaparin and Apixaban were selected to evaluate the rate of complications, as assessed by Clavien-Dindo classification, thromboembolic events, and 30-day mortality, readmission, and reoperation rate between the two anticoagulants.

RESULTS

130 patients were included in the analysis. 65 patients received Apixaban and Enoxaparin in each group. Mean age of the participants was 57.6±11.0. 83.1% underwent laminectomy and posterior spinal fusion, while 22 patients underwent decompressive surgery only. The incidence of venous thromboembolism (P-value=0.403), deep vein thrombosis (p-value=0.999), hematoma formation (p-value=0.403), surgical site infection (p-value=0.901), readmission (p-value=0.545), reoperation (p=0.510), mortality (p=0.648), and complications rate (p-value=0.232) were not statistically different between Enoxaparin and Apixaban.

DISCUSSION

Both Apixaban and Enoxaparin may be viable options for postoperative thromboprophylaxis in spine surgeries with comparable efficacy and safety profile. Future research endeavors should investigate the efficacy of these agents in comparison to placebo in a randomized setting.

Chemical prophylaxis and venous thromboembolism following elective spinal surgery: A systematic review and meta-analysis

Background

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a potentially devastating complication after surgery. Spine surgery is associated with an increased risk of postoperative bleeding, such as spinal epidural hematomas (SEH), which complicates the use of anticoagulation. Despite this dilemma, there is a lack of consensus around perioperative VTE prophylaxis. This systematic review investigates the relationship between chemoprophylaxis and the incidence rates of VTE and SEH in the elective spine surgical population.

Methods

A comprehensive literature search was performed using PubMed, Embase, and Cochrane databases to identify studies published after 2,000 that compared VTE chemoprophylaxis use in elective spine surgery. Studies involving patients aged < 18 years or with known trauma, cancer, or spinal cord injuries were excluded. Pooled incidence rates of VTE and SEH were calculated for all eligible studies, and meta-analyses were performed to assess the relationship between chemoprophylaxis and the incidences of VTE and SEH.

Results

Nineteen studies met our eligibility criteria, comprising a total of 220,932 patients. The overall pooled incidence of VTE was 3.2%, including 3.3% for DVT and 0.4% for PE. A comparison of VTE incidence between patients that did and did not receive chemoprophylaxis was not statistically significant (OR 0.97, p=.95, 95% CI 0.43-2.19). The overall pooled incidence of SEH was 0.4%, and there was also no significant difference between patients that did and did not receive chemoprophylaxis (OR 1.57, p=.06, 95% CI 0.99-2.50).

Conclusions

The use of perioperative chemoprophylaxis may not significantly alter rates of VTE or SEH in the elective spine surgery population. This review highlights the need for additional randomized controlled trials to better define the risks and benefits of specific chemoprophylactic protocols in various subpopulations of elective spine surgery.